Know Your Solutions
It is critical to clearly understand the mechanisms of action of the peels you use, as well as their depth of penetration. Peel solutions can be straight acids at varying percentages, combinations of multiple peeling agents, or blends of several peeling agents in conjunction with other key ingredients like melanogenesis inhibitors and skin strengthening agents. It is important to be cognizant of this, as some peels are easier to use and more suitable for a wide variety of patients, while others are capable of creating a full thickness burn and should only be performed on a specific type of patient (potentially only once or twice in their lifetime). Always be certain that the solution you are using is allowed under your particular licensure. Typically, clinicians who are not medical doctors will only perform superficial peels. Each option can produce beneficial results, but all have varying application techniques. Some are timed and rinsed off, while others are left on the skin. Some peel solution application techniques contraindicate the application of water, while removal with water is required for others. So, you can see that participating in as much additional training with the company whose treatments you choose to use is of critical importance. Not only will it allow you to get the best results possible for all your patients, but this deep knowledge could also prevent unintentional negative outcomes and unnecessary complications.

Pairing Patients with Peels
Each patient that is a candidate for a chemical peel should undergo a thorough consultation that includes taking a detailed patient history, visual inspection of the skin, taking "before" photographs, and the signing of an informed consent form. Once you have a good working knowledge of the patient's skin challenges, desired results and level of compliance, you should then start them on a basic daily care regimen to prepare their skin for their first peel. This two-week pre-treatment period typically reduces the chances of complications quite dramatically. Also, since the clinician is in control of what pre-treatments the patient is using, the chances of the skin being compromised or a negative reaction at the time of treatment occurring are limited.

You should also consider the following when selecting the appropriate treatment for each patient:

• Fitzpatrick Type – Peel solutions that create copious amounts of surface stimulation or that are designed to achieve medium-depth should be reserved for lower Fitzpatrick types. Chemical peeling is appropriate for higher Fitzpatrick types, but should be limited to superficial peeling agents that create minimal surface stimulation. This will minimize the chances of over-treatment and post-inflammatory hyperpigmentation. Also, be cognizant of the fact that many of your patients may be of mixed heritage. Someone's outward appearance will not always give you a full understanding of their skin's predispositions (for example, a blond, light-skinned individual with Asian/Nordic ancestry).
• Allergies or sensitivities – Any ingredients to which a patient is allergic should be identified on their patient consultation forms and assessed for level of risk (a rash versus anaphylaxis).
• Patient compliance and demeanor – It is critical that you take the time to educate your patients about the importance of following your recommendations pre- and post-treatment, especially for the patient that has come to you wanting dramatic and immediate results. During your consultation, ensure they have realistic expectations. Many patients still have the "more is better" mentality and think that if they do more than what you recommend, they will get faster results. Make sure they understand that inflammation is the enemy. Advise the patient that if they use aggressive topicals when you have advised against it, or if they seek out treatment from another clinician sooner than you recommend is healthy for their skin, they will end up with negative outcomes. It is our job to help consumers understand the importance of their part in achieving their goals. If you suspect a patient may not follow your guidelines or is someone who has had challenges with other clinicians, opt for performing facials – not peels.

When Complications Occur
Although complications with superficial chemical peels are unlikely if applied properly to the appropriately selected patient, it is important for a responsible clinician to know how to address them should they occur. Always have the number of the peel company with whom you work at hand to call in the event of a complication. It is also wise to have the number of a medical practice that you trust available for extreme, yet unlikely cases. Some possible complications to consider include:

• Periorbital edema (puffy eyes) – Mild to moderate swelling is a normal outcome for some patients following chemical peels. This is not considered a true complication, but simply a side effect. Regardless, it can be disconcerting to patients, so let them know ahead of time that if this happens, it will pass quickly and is considered normal. To soothe the puffy areas, they can apply a cool cloth and sleep with their head slightly elevated to reduce swelling. They should not apply ice packs, as this will tend to worsen the condition rather than improve it.
• Allergic reactions – Some ingredient allergies will cause a mild histamine response, rash and pruritus (itchiness), which can be relatively easily addressed with oral anti-histamines and topical anti-inflammatory topicals like OTC 0.5 to one percent hydrocortisone cream or something similar from the skin care company you carry in your practice. Of course, it is best to avoid even minor allergic responses, so performing a patch test in front of or behind the ear at least one week prior to treatment with a product containing potentially sensitizing ingredients (for example hydroquinone) is recommended to gauge the level of reaction prior to peeling.
• Blanching – Protein coagulation usually occurs only from the application of medium-depth and deep peels, procedures only physicians should perform as they are highly invasive. Skin care clinicians who are not physicians or working under their advisement should not perform these types of treatments, as they pose a much greater risk of complication. When performing peels, use some type of sensitivity scale to help to determine and track patient sensitivity. Some clinicians use a scale of one to 10 for this purpose. If a patient is telling you they are approaching a five or six on the scale of one to 10, avoid adding any more active solution or other topicals and end the treatment with soothing agents and broad spectrum sunscreen. You will almost always avoid blanching (burning/protein coagulation) and uncomfortable situations if you follow this guideline. If a patient is peeled too deeply, blanching and open oozing areas may result. Keep in mind that if a patient's peel penetrates deeper in some areas, those areas will have a pH closer to blood (7.3 to 7.4) than intact skin (5.5). Products must be chosen carefully to accommodate for this change in pH. If spot blanching occurs, only an occlusive lubricant should be applied to keep those areas protected and moist. Advise the patient that they will likely peel more in those areas and may have some temporary darkening at the blanch site until it peels. With proper care, the skin discoloration should clear without further intervention. If the affected patient is a higher Fitzpatrick type, a follow-up treatment for post-inflammatory hyperpigmentation may be necessary. Once the area is re-epithelialized (approximately 48 hours), suggest gentle topicals that encourage the production of natural moisturizing factor (NMF). Then, once their skin returns to baseline, they can resume the use of their recommended post-procedure skin care regimen.

With the variety of chemical peels growing and patient desire for dramatic results increasing, it is our job as skin health professionals to continually expand our knowledge and skills. We know that helping others achieve their skin health goals is not only rewarding, but can be life-changing for patients. Through careful and responsible treatment, we can provide dramatic, visible results for all our patients while avoiding unnecessary complications.

Cheryl Staurowsky, LE, PCA skin advanced educator, since 2003. Staurowsky lives in Ft. Lauderdale, Fla. and began her career in medical aesthetics in 1994. While working with a variety of skin conditions and medical devices at multiple renowned physicians' offices, she became skilled at customizing professional treatments and daily care regimens. Staurowsky has a passion for knowledge and educates her patients on the benefits of skin care and how a formulation actually works within the skin.